Q380 Dr Stoate:
Does either of you expect it to make much of a difference?

Mr Parkes: Personally I think
that for it to make a significant difference we would probably
need to have a greater figure than the 1.5% and it would probably
need to be there as a reward rather than part of a base payment.

Ms Garbutt: I agree with that.

Q381 Charlotte Atkins:
John, you mentioned that the Operating Framework sets CQUIN at
1.5% but they are talking about the possibility of it rising to
10% in 2011-12. Are you comfortable with that and also have you
ever fined one of your providers for poor performance, such as
infection?

Mr Parkes: Yes, we absolutely
have fined and we do it quite deliberately in order to try and
get that balance between rewards and penalties as a means of influencing
behaviour. I would be interested in the move towards 10% but I
am worried that if that is part of the base funding it could have
a destabilising effect, so I think perhaps the clever thing

Q382 Charlotte Atkins:
Can you explain that a bit more? Why would it be destabilising?

Mr Parkes: If I went back into
running a hospital, if I potentially lost 10% of my income because
I had failed CQUINS without there being a proper period of notice
for recovery, it would have the ability to destabilise me financially,
so I think the 10% would have to have periods of notice and periods
of improvement before the 10% was either earned or removed.

Q383 Charlotte Atkins:
In terms of fining for performance, can you give an example of
that, and did it improve performance in future?

Mr Parkes: We have certainly fined
providers in the past for failing to achieve things like A&E
targets, and, depending upon their financial position, it has
either had an impact or not. It is probably more the threat of
it that is the real value.

Q384 Charlotte Atkins:
Julie?

Ms Garbutt: We have not fined,
although the threat of that fine is there. I think for the reason
that John said, unless you are talking about really sizeable chunks
of money it is not going to have the desired effect. We need to
incentivise more but I think there has to be the ultimate sanction
if, after periods of recovery and notice, you are not getting
improvements.

Q385 Charlotte Atkins:
From April 2009 the Patient Related Outcome Measures were introduced
into the NHS in four areas: hips, knees, hernias and varicose
veins. Where that shows poor performance will you alter your commissioning?
You have already mentioned this, John, that you have altered your
commissioning in some ways.

Mr Parkes: Yes, and one of the
things that we want to do is use that information to help patients
make choices around where they want to go for their elective surgery.

Q386 Charlotte Atkins:
But the evidence shows that patients are more likely to decide
where they go on the basis of what the car parking is like rather
than the quality.

Mr Parkes: I absolutely agree.

Q387 Charlotte Atkins:
They look to their GP, do they not, to advise them which hospital
to go to because they do not usually feel competent or aware enough
to be able to choose?

Mr Parkes: If I need my hip doing,
there is a model that says, "An expert orthopaedic nurse
will call you tomorrow. We will talk through the treatment options,
agree with you success, be it reduced pain or increased mobility,
and we will share with you who the local providers are, the local
surgeons, and what the feedback is in terms of outcome and patient
satisfaction", and experience from other economies shows
that the public like that because it is a half-hour conversation
rather than a five- or ten-minute one, and it also in some instances
results in people saying, "No, I do not want that operation
because of the potential risk or lack of benefit to me",
and we are wanting to get to a position where we pilot that in
Northamptonshire.

Ms Garbutt: I think it is very
early days still with PROMs, but I think making that sort of information
available to patients does empower them to make different choices,
and particularly the one about choosing not to proceed with having
treatment is very important. Although, obviously, clinicians do
go to great lengths to explain the pros and cons of any particular
treatment that they are suggesting, I think knowing how other
people have got on and what their experience has been and whether
it is a total success or not is very useful in terms of empowering
the patient to make their own choices.

Q388 Charlotte Atkins:
Including deciding not to be treated?

Ms Garbutt: Yes.

Q389 Charlotte Atkins:
Do you think that fines have a problem in terms of maybe destabilising
your local health economy, or is it just about shifting financial
pressures from yourselves to providers? How do you see fines?

Mr Parkes: I think I have a role
in terms of managing risk, and risk to the patient is at the forefront
of my mind so I would want fines to be used to mitigate that risk,
but at a secondary level I do not want to completely destabilise
my providers, I want to have a professional relationship with
them. My health economy would know that if we are having high
cost, poor services, they will be put out to the market and market
tested to see whether there are other people out there able to
provide better quality at reduced cost.

Q390 Dr Taylor:
World Class Commissioning in one minute. What difference has it
made to the work you do? You have given us a list of things: the
SWAN Partnership, Child and Adolescent Mental Health from Northants
and Telehealth stroke services and things like that, so why could
you not do those in any case? What has World Class Commissioning
done to allow you to do that?

Mr Parkes: I think it has allowed
me to move from a spending regime to an investment regime because
it has set out almost a set of exam questions that represent good
practice that I know I should be aiming to achieve, so that whole
testing of what are now 11 competencies and being clear around
what excellent is in those 11 competencies has allowed me to develop
the form and functioning within my commissioning organisation.

Q391 Dr Taylor:
It has really just been a way of focusing your efforts on the
right way to go?

Mr Parkes: It has given me a whole
set of questions that I have had to answer in terms of making
myself a World Class commissioner, absolutely not there but I
can see the journey and I can see where I need to get to.

Q392 Dr Taylor:
You did, I think, rather better than Norfolk on the scores. Julie,
why did you not do quite so well on the scores? How were the scores
worked out?

Ms Garbutt: I would probably start
off by saying I think it depends on where you start from. A number
of the PCTs that did particularly well and boast very good scores
were ones that had not been reorganised, so they were able to
hit the ground running, they did not have the instability of having
to reorganise, reappoint people, et cetera. We had a very complex
and difficult reorganisation. The five previous PCTs did not particularly
want to merge. They had not done much in the way of transition
planning and, as they did come together, the ledgers proved that
there was a 50 million deficit. I could say, therefore, no wonder,
but I am also very conscious that John is sitting next to me and
he had much the same start and he performed much better, so I
do not think that can be a legitimate response. When I reflected
on it I was saying two things. The first is that we did not have
the capacity and capability in place that we needed, and the second
is that is we did not have a strong strategic plan, and both those
things feature very heavily in terms of whether you can demonstrate
you are delivering competencies, and the strategic plan determines
whether you are agreeing on your governance, your finance and
your strategy. What I can say is, since we have had that experience,
we have now got a first-class five-year strategic plan which has
been benchmarked and agreed by our strategic health authorities
as one of the best it has seen. We have a very comprehensive organisational
development plan. We were supported both by external consultancy
to make sure we were challenged and we have made great inroads
to implementing those. I do intend and expect that we will do
much better in the round that we are now in, but we were where
we were and we needed to move fast. The good thing about world-class
commissioning is it gives us very clear standards and very clear
benchmarks and there is nowhere to hide.

Q393 Dr Taylor:
Did it make you focus more on competency, engaging the public
and partners?

Ms Garbutt: No, we were stronger
in engaging public and partners and in system leadership. Our
weaknesses were in the technical competencies, the market making,
the utilisation of information, contract management, all areas
in which we have significantly boosted our competences in terms
of capability and capacity.

Q394 Dr Taylor:
How much did either of you use the external organisations? We
are told in the Framework for procuring External Support for Commissioners
there are 14 private sector companies that you can call on for
support.

Ms Garbutt: Yes.

Q395 Dr Taylor:
Did you use those? How much did you spend on those?

Ms Garbutt: We used external support
from the FESC agencies to develop our commissioning processes
through our commissioning boards, we used them to support us in
developing the strategic plan, we used them to support us in developing
our organisational delivery plan. We also used a number of interim
agency appointees to boost senior leadership in the PCT whilst
we embedded those practices in the PCT and we made substantive
appointments. The investment was quite substantial and would run
into millions.

Q396 Dr Taylor:
Do you think that investment is going to pay off?

Ms Garbutt: Yes, I do.

Mr Parkes: We have the largest
FESC contract in the country and regularly use external management
consultants. I have no issue with that as long as whatever I am
spending I can actually demonstrate that by so doing they have
added real value. So far we have had no problem with a number
of our external consultancies but, as with any external company,
they do need to be managed and I am sure at some point we will
part company with some but will play in others.

Q397 Dr Taylor:
This would be one of the large proportions of money spent across
the NHS on management consultants?

Mr Parkes: Yes.

Dr Taylor: Thank you.

Q398 Dr Naysmith:
A final question. What would you like to see the Government do
to help you to improve? That question could be framed another
way. Do you want to be left alone or do you want further reform?

Mr Parkes: I certainly do not
feel the need for further reform, and I think there is good evidence
that says we tend to reform things on a three-year cycle when
most things take six years before they reach their optimal level.
I do not want to be reformed, but I do think that there are things
that you could do, for example giving me access to the primary
care data that would allow me to become a more effective commissioner
but would allow clinicians to be more effective practitioners.

Ms Garbutt: Give us time to bed
in. Please, no more re-organisations. Continue to support the
shift in terms of the balance of power, so more of the changes
around the tariff to enable us to move money around the system,
and a slimmed down intermediate tier, please. We need to maximise
the devolution of the money and the responsibilities to the frontline.

Dr Naysmith: Thank you both very much
indeed. You have given us a lot of useful information that will
help us to write our report. Thank you.